PENTICTON VEES JR ‘A’ HOCKEY CLUB
PLAYER INFORMATION SHEET
JERSEY: COLOUR: ___________________
PLEASE DO NOT WRITE IN THIS SPACE:
No: _________
COMPLETED FORM MUST BE RECEIVED PRIOR TO START OF CAMP
PLAYER
NAME ______________________________________
B.C. MEDICAL HEALTH INSURANCE:
YES
AGE: _______

NO

BIRTH DATE M ________ D _____ 19_______
CARD NUMBER:__-________________________
OTHER PROVINCIAL INSURANCE and/or ADDITIONAL FAMILY INSURANCE:
YES

NO

PROVINCE and / or NAME OF INSURANCE COMPANY: _____________________________________________________
POLICY NOS: ________________________________________________________________________________________
YOUR ADDRESS: ______________________________________
TELEPHONE: [H] ( ____ ) ________ - __________
______________________________________
[C] ( ____ ) ________ - __________
______________________________________
POSTAL / ZIP CODE
________________
E / Mail: ___________________________________
IF YOU ARE A U.S. PLAYER, YOU MUST HAVE PRIMARY HEALTH INSURANCE COVERAGE. PLEASE ENSURE YOU
HAVE A COPY OF YOUR COVERAGE WITH YOU AT ALL TIMES DURING THE CAMP.
NAME OF INSURER : __________________________________________________ POLICY No. _____________________
EXPIRY DATE : Month : ________________
Day : _______
Year : ______________
PARENTS
MOTHER ________________________
TELEPHONE: [H] SAME AS ABOVE

OR ( ______ ) ________ - ___________
[C] ( ________ ) __________ - _________________
[W] ( ________ ) __________ - _________________
FATHER ________________________
TELEPHONE: [H] SAME AS ABOVE

OR ( ______ ) ________ - ___________
[C] ( ________ ) ___________ - _________________
[W] ( ____)___ ) ___________ - _________________
EMERGENCY CONTACTS
FAMILY PHYSICIAN _______________________________________ TELEPHONE [W] ( _____) ________- ___________
PERSON TO CONTACT IN ACCIDENT OR EMERGENCY,
IF PARENTS CAN NOT BE CONTACTED
NAME ________________________________________
RELATIONSHIP ________________________________
TELEPHONE [H] ( _____) ________- ___________
[C] ( _____) ________- ___________
[PLEASE COMPLETE REVERSE SIDE OF FORM]
(CONFIDENTIAL WHEN COMPLETED)
PLAYER MEDICAL INFORMATION
A) HEIGHT: _______ FT. _______ IN.
WEIGHT: _________ LBS.
B) Date of last complete Physical examination.
_________________________
Date of Last TETANUS BOOSTER (Check one): Less than 3 yrs
:
3 - 5 yrs
:
More than 5 yrs

C) Please check the appropriate responses:
YES
Allergies to Medication
NO

YES

Wears glasses
Allergies - other


Are lenses shatter proof

Asthma


Wears contact lenses

Diabetic


Hearing Problem

Epileptic


Wears Medic Alert bracelet / necklace  
Heart Condition


Wears dental bridges, plates or braces 
Medication or other supplements [vitamins etc.] being regularly taken at home

Has had an illness lasting more than a week in the past year

Has had injuries requiring medical attention in the past year [clinic outpatient basis] 
Has been hospitalized in the past year

Has had a surgical operation in the past year

Has had one or more concussions in the past 2 years

Has had injuries to his head, back or joints in the past 2 years

Other health problems that may interfere with participation in a full hockey program 
Are you presently recovering from an injury

NO

N/A













PLEASE PROVIDE ADDITIONAL INFORMATION TO ANY OF THE ABOVE RESPONSES CHECKED AS “YES”
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
D) PLEASE ENTER ANY ADDITIONAL INFORMATION NOT COVERED ABOVE WHICH MAY AFFECT YOUR ABILITY TO
PLAY A FULL HOCKEY PROGRAM
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
E) I understand that it is my responsibility to immediately advise the Camp Training staff of any change in
the above information.
In the event no one can be contacted, the Camp training staff or management will admit the player to
the hospital if deemed necessary.
Authorization is hereby provided to the training staff as well as the physicians and nursing staff of any
Hospital or Emergency Unit to undertake necessary examination, investigation and necessary treatment
of the player.
___________________
DATE
___________________
DATE
_________________________________________________________________
PLAYER’S SIGNATURE
_______________________________________________________________
PARENT OR GUARDIAN SIGNATURE
[ REQUIRED IF PLAYER IS UNDER 18 YEARS ]
COMPLETED FORM MUST BE RECEIVED PRIOR TO START OF CAMP